ICL 9.8: Puerperal Psych

Question 1

what are the 2 important things from this whole lecture?

Answer 1

1. permpartum onset as a specifier for any psychiatric illness within 4 weeks of delivery
2. what’s normal for baby blues vs. MDD

Question 2

what does puerperal mean?

Answer 2

“puerperal” is an obstetric adjective from the noun “puerperium” which is the period during which the pregnant uterus returns to its nonpregnant state (often 6 wks)

Question 3

how do psychiatric illnesses play a role in pregnancy?

Answer 3

so some people have a pre-existing psychiatric illness and then they become pregnant

others become pregnant then they display symptoms of psychiatric illness

when you become pregnant there’s lots of changes and this effects the brain!

Question 4

what are the psychological stages of pregnancy?

Answer 4

1. acceptance of the pregnant state
2. affiliation with the fetus
3. preparatory behavior
4. development of a reality-based perception of the neonate

Question 5

what are the psychosocial adjustments of pregnancy?

Answer 5

1. new role as mother

2, marital relationship

3. possible decreased $ income
4. decreased sleep, chronic fatigue
5. cramped living environment
6. loss of libido

Question 6

what is the DSM5 criteria for “with peripartum onset”**

Answer 6

In the DSM-5, the specifier “with peripartum onset” can be applied to:

1. Major Depressive Disorder
2. Bipolar I Disorder, any phase
3. Bipolar II Disorder, any phase
4. Brief Psychotic Disorder

onset of mood symptoms occurs during pregnancy or in the 4 weeks following delivery

50% of “postpartum” major depressive episodes actually begin prior to delivery!!

Question 7

what is pregnancy brain?

Answer 7

it’s debatable whether women experience neurocognitive changes across pregnancy

neurocognitive functions including memory may be negatively affected by pregnancy, due to changes in sex hormone production:

1. higher levels of progesterone were associated with a higher rate of negative mood states
2. estrogen and cortisol were negatively associated with attention scores in the postpartum period
3. prolactin levels were associated with verbal memory and executive functioning scores during pregnancy

Question 8

how are anxiety and pregnancy related?

Answer 8

nearly 1/3 of women experience an anxiety disorder during their lives, with peak onset during child-bearing years

compared with research on perinatal depression, far fewer studies have examined anxiety disorders

a woman in her first pregnancy may be at increased risk to develop an anxiety disorder if she has a comorbid medical condition

Question 9

what are the effects of an anxious mom on the fetus?

Answer 9

1. maternal anxiety in pregnancy is a risk factor for mom having post-natal depressive symptoms like a depressed mood, or less able to respond sensitively and competently to their newborns
2. maternal anxiety in pregnancy causes INCREASED uterine artery resistance (affects placenta)
3. does not DIRECTLY cause IUGR or preterm delivery

Question 10

how do we treat anxiety during pregnancy?**

Answer 10

no studies directly address the efficacy or outcome of any psychotherapy for anxiety in pregnancy

for mild to moderate anxiety, psychotherapy is first line!!

there’s no evidence to suggest that pregnant women with anxiety require different therapy targets than as other psychiatric patients

Question 11

what are baby blues?

Answer 11

it’s normal to be a little sad after giving birth! postpartum blues are normal and is seen within 7-10 days after giving birth (compared to postpartum which can happen up to a month later)

symptoms include emotional lability, tearfulness, confusion, insomnia and anxiety

normal postpartum adjustment includes sleep disturbances and loss of sexual interest

however, not normal and thus indicative of potential MDD include cognitive symptoms, loss of energy, guilt and anhedonia

risks include primiparous and history of PMS

Question 12

how do you treat baby blues?

Answer 12

therapeutic interventions include anticipation and reassurance

also get some sleep** and tell them it’s normal and will pass!

Question 13

what causes postpartum mood symptoms?

Answer 13

1. neuroendocrine fluctuations

during pregnancy, there are high levels of estradiol (placental origin), and the thyroid and anterior pituitary enlarge

after delivery, there’s a precipitous drop in circulating progesterone, estradiol, and cortisol in the puerperium

2. in general, post partum women have higher levels of cortisol, prolactin, thyroxine, and estrogen than non-puerperal women
3. estrogen acutely antagonizes dopamine activity (by decreasing dopamine production and blocking activity at dopamine receptors) – so as estrogen is rapidly decreased after delivery, the dopamine system is super-sensitized; may contribute to postpartum mania or psychotic depression

Question 14

how is the hypothalamic-pituitary axis involved with pregnancy?

Answer 14

depression is already known to disrupt the HPA axis

in pregnancy, the placenta independently produces CRH, ACTH, and cortisol
which are regulated in a feed-forward way, that leads to down-regulation of auto-receptors in the hypothalamus and anterior pituitary of mom

Question 15

how is the immune system effected by pregnancy?

Answer 15

delivery of a newborn stimulates a pro-inflammatory state presumably attributable to pain, physical exertion, and tissue injury involved in delivery

pro-inflammatory cytokines are already linked to altering the HPA axis, and associated with depression

interleukin-1beta a potent pro-inflammatory cytokine released from WBCs, is elevated in the first month post-partum

pro-inflammatory cytokines are associated with depression and schizophrenia!!

Question 16

how do we prevent depression during/after pregnancy?

Answer 16

want to prophylactically treat with antidepressant after delivery in those at HIGH risk (reduces relapse from 62% to ~7%, or 68% to 26% depending on which study you look at)

women who stop antidepressants are 5x more likely than women who continue medications in pregnancy to have a relapse of depression

50% relapse by first trimester

90% relapse by second trimester

Question 17

what are the risk factors for depression in peripartum time?

Answer 17

1. history of depression (50-62% risk of postpartum episode)

women with history of 4 or more previous episodes were at higher risk

2. stopping antidepressant medication
3. family history of depression
4. limited support;
5. living alone
6. greater number of children
7. marital conflict
8. ambivalence about the pregnancy
9. having experienced “baby blues”

Question 18

what are the effects of maternal depression on the mom?

Answer 18

1. poor self care
2. substance use
3. suicide
4. postpartum depression

Question 19

what are the effects of maternal depression during pregnancy and labor?

Answer 19

1. poor prenatal care
2. increased risk of intrauterine exposure to AOD
3. increased exposure to maternal cortisol with resulting neurodevelopmental changes,
4. preterm delivery (from increased ACTH, cortisol)
5. pre-eclampsia (2-3x higher)
6. low birth weight
7. failure to thrive

Question 20

what are the effects of maternal depression long term on the child?

Answer 20

1. elevated cortisol levels
2. poor stress adaptation, insecure attachments
3. decreased cognitive performance
4. behavioral difficulties
5. poor mother-child bonding

Question 21

which medication is approved for postpartum depression?

Answer 21

brexanolone

pretty impractical though because it’s $34,000 and is a continuous IV infusion that has to be given right after birth

Question 22

what is premenstrual dysphoric disorder?

Answer 22

PMDD is something that about 75% of women experience

it’s a premenstrual change in emotional or physical symptoms commonly referred to as premenstrual syndrome (PMS) but it’s like worse than PMS because it messes with function

about 3-9% of women experience moderate to severe symptoms that meet criteria for the mood disorder PMDD (about 19% are subthreshold), although about 90% may go undiagnosed

although PMS and PMDD share affective and somatic symptoms, more symptoms are required for PMDD, and symptoms are more severe

Question 23

how do you treat premenstrual dysphoric disorder?

Answer 23

1. hormonal interventions
2. the use of combined oral contraceptives (estrogen and progestin) is common
3. spironolactone (aldosterone antagonist) improved irritability, depression, feelings of swelling, breast tenderness, and food craving in women with PMS
4. antidepressants used only during 2 weeks when you’re having MS

Question 24

what is infanticide?

Answer 24

murder of a child

neonaticide is murder of when the child isa neonate or younger than 24 hours old

Question 25

what are the risk factors for a woman committing infanticide?

Answer 25

1. if had denial of pregnancy or birth
2. delusions that baby is dead or defective
3. hallucinations commanding the mother to hurt the baby
4. La belle indifference
5. within 6 months of birth
6. alcohol use
7. limited social support
8. personal history of abuse

untreated postpartum psychosis has a 4% risk of infanticide

estimated that 1-5% of SIDS cases are actually infanticide

can be culturally endorsed (killing infant females in China & India), and occurs across species (gorillas, dolphins)

Question 26

what is the obstetric and neonatal impact of anxiety disorders?

Answer 26

obstetric impact = increased use of forceps deliveries, prolonged labor, precipitated labor, fetal distress, preterm delivery, and spontaneous abortion

neonatal impact =
decreased developmental scores and inadaptability, slowed mental development at 2 years of age

Question 27

what is the obstetric and neonatal impact of major depression disorder?

Answer 27

obstetric impact = increased incidence of low birth weight, decreased fetal growth, and postnatal complications

neonatal impact = increased newborn cortisol and catecholamine levels, infant crying, rates of admission to NICUs

Question 28

what is the obstetric and neonatal impact of bipolar disorder?

Answer 28

obstetric impact = increased incidence of low birth weight, decreased fetal growth, and postnatal complications

neonatal impact = increased newborn cortisol and catecholamine levels, infant crying, rates of admission to NICUs

Question 29

what is the obstetric and neonatal impact of schizophrenia?

Answer 29

obstetric impact = increased incidence of preterm delivery, low birth weight, small for gestational age, placental abnormalities, and antenatal hemorrhage

neonatal impact = Increased rates of postnatal death

also teratogenicity like congenital malformations, cardiovascular system!

Question 30

if you’re thinking about getting pregnant, what are the ACOGG recommendations?

Answer 30

for women on medication with mild or no symptoms for >6 months, it may be appropriate to taper and discontinue medication before becoming pregnant

medication discontinuation may not be appropriate in women with a history of severe, recurrent depression, or who have psychosis, bipolar disorder, other psychiatric illness requiring medication, or a history of suicide attempts***

Question 31

what are the ACOGG recommendations for pregnant women currently taking medication for depression?

Answer 31

psychiatrically stable women who prefer to stay on meds may be able to do so after consultation between their psychiatrist and obstetrician to discuss risks and benefits

women who want to stop meds may attempt to taper and discontinue if they are not experiencing symptoms, depending on their psychiatric history

women with recurrent depression or who have symptoms despite medication may benefit from psychotherapy to replace or augment medication

women with severe depression (SA, functional incapacitation, or weight loss) should remain on meds***

Question 32

what are the ACOGG recommendations for pregnant women not currently on meds

Answer 32

psychotherapy may be beneficial for women who prefer to avoid antidepressants

for women who want to take medication, risks and benefits of treatment choices should be evaluated and discussed, including factors such as stage of gestation, symptoms, history of depression, and other conditions

Question 33

what are the ACOGG recommendations for ALL pregnant women?

Answer 33

regardless of circumstances, a woman with suicidal or psychotic symptoms should immediately see a psychiatrist

Question 34

how can electroconvulsive therapy be used for a pregnant person?

Answer 34

it’s actually really safe and can be used in all trimesters!

it’s used for severe depression, acute suicidal tendencies, depression with psychosis, severe dehydration and malnutrition

Question 35

how does bipolar disorder effect pregnancy?

Answer 35

40% - 70% of bipolar women will experience postpartum mania or depression (this is decreased to 10% with mood-stabilizer prophylaxis)

if you have bipolar disorder, and have family history of psychosis during pregnancy, you’re risk of experiencing puerperal psychosis is 50-60%

if prior history of bipolar illness with psychotic features during peripartum, risk of another is 75-90%

medicate prophylactically (lithium, carbamazepine, olanzapine, quetiapine)

AVOID SLEEP DEPRIVATION! get nocturnal infant care

Question 36

how does schizophrenia effect pregnancy?

Answer 36

1. preterm delivery
2. low birth weight
3. small for gestational age
4. placental abnormalities
5. antenatal hemorrhage
6. increased rates of congenital malformations, especially of the cardiovascular system
7. greater risk of requiring interventions during labor (labor induction, assisted or C-section)
8. psychiatric illness will most likely worsen during pregnancy; high association with denial of pregnancy; 65% of women with schizophrenia who do not maintain medication will relapse during a pregnancy
9. about 1/4 of women with schizophrenia become acutely psychotic within 6 months after delivering a baby

Question 37

what is puerperal psychosis?

Answer 37

described in studies as mainly affective, functional psychosis with good prognosis (bipolar or schizoaffective) with ~75% returning to baseline – looks like a delirium

~0.1% of all women experience this

usually described as an agitated, confused, almost delirious state, with marked disturbance of sleep, hallucinations, bizarre delusions and violent behavior with abrupt onset within days of delivery

no exact DSM diagnosis exists

moms with h/o bipolar disorder or postpartum psychosis have 100x increase in rates of psychiatric hospitalizations in the postpartum period!!!!

social factors appear to play less important role in post-partum psychosis than depression

Question 38

what’s the difference between psychosis and OCD?

Answer 38

In postpartum OCD, women may experience intrusive thoughts of accidental or purposeful harm to the baby BUT they are still in touch with reality

OCD thoughts are ego-DYSTONIC

41 / 100 depressed mothers acknowledged having thoughts of harming their infants

Question 39

what is Pseudocyesis/Delusional pregnancy/Simpson’s Syndrome?

Answer 39

condition where signs and sx of pregnancy appear, or are simulated, in whole or in part

Question 40

what is a simulated pregnancy?

Answer 40

says they’re pregnant when they know they’re not

Question 41

what is pseudopregnancy?

Answer 41

tumor creating endocrine changes suggestive of pregnancy

Question 42

what is couvade syndrome?

Answer 42

when man develops sx of pregnancy when his wife becomes pregnant but knows he’s not pregnant himself

Question 43

what are the medication issues when giving meds to depressed pregnant women?

Answer 43

ALL psychotropic medications cross the placenta, are present in amniotic fluid, and can enter human breast milk

Prefer :
single medication at a higher dose versus multiple medications

meds with fewer metabolites

meds with higher protein binding (decreases placental passage)

fewer interactions with other medications

Question 44

what is the best antidepressant for pregnant women?

Answer 44

sertraline

can be used during pregnancy and breastfeeding